ACID BASE

BALANCE AND
DISORDERS
12/8/21 By
Dr Madanika P
Ions Na+ K+
Cell
• Definition: Any particle Ca++
PO4---
which carries charge Cl- ECF
• Types:
●
Negatively charged . Move towards
Anions ●
anode
Eg: Cl- , HCO3-,PO43-, OH -

●
Positively charged. Move towards

Cations ●
Cathode
Eg: K+,Na+ ,Ca2+ ,H+,
12/8/21
Why charges on molecules are important?

• Rate of enzyme catalyzed reaction

• Maintain stability & confirmation of
proteins
• Interaction of macromolecules with
each other & with small ions
• Analytical & purification techniques in
the laboratory

12/8/21
H+ ion -it must be
maintained in narrow
range in order to be
compatible with living
systems
Free H+ ion –40nmol/L
Being small ion highly
reactive
Small fluctuation can
affect normal functions
Buffers regulate the
H+ ion concentration

4
 Importance of Hydrogen Ion
• Creates a gradient across
membrane
• Maintenance of PH of body
fluids
• Gradient is important
To stimulate oxidative
phosphorylation
Ionisation of weak acids and
bases and facilitates their
physiological function
Affects surface charge of Proteins
12/8/21
 Arrhenius theory
1887--- Ionic theory
1. Electrolyte splits into charged particles(ions)
in solution .
2. Ions carry electric current
3. Positive charges = Negative charges. Solution
is neutral.
4. Degree of ionization increases with dilution
in weak electrolytes.
5. Chemical changes occur due to reaction
between charges and not molecules.
12/8/21
 Definition
• Acid is any substance which
dissociated in water to produce H+ ion
• Base is any substance which
dissociated in water to produce OH- ion

• Holds good for aqueous solutions only

• Cause for dissociation not explained

12/8/21
 Bronsted and Lowry concept

• Acid: Any Substance or particle or

Ion which donates Hydrogen ion.
• Eg: HCl, H2CO3.

• Base: Any Substance or particle or Ion

which accepts Hydrogen ion.
• Eg: HCO3-, CH3COO-
• Explains conjugate acid base pairs
12/8/21
ACIDS

9
 ACIDS
• Acids can be defined as a proton (H+) donor
• Hydrogen containing substances which
dissociate in solution to release H+

Click Here

10
 ACIDS
• Acids can be defined as a proton (H+) donor
• Hydrogen containing substances which
dissociate in solution to release H+

H+
OH
H+ -

OH-

H+

O -
H-
OH

H+

11
 ACIDS
• Physiologically important acids include:
– Carbonic acid (H2CO3)
– Phosphoric acid (H3PO4)
– Pyruvic acid (C3H4O3)
– Lactic acid (C3H6O3)
• These acids are dissolved in body fluids
Phosphoric acid
Lactic acid

Pyruvic acid

12
BASES

13
 BASES
• Bases can be defined as:
– A proton (H+) acceptor
– Molecules capable of accepting a hydrogen
ion (OH-)

Click Here

14
 BASES
• Physiologically important bases include:
– Bicarbonate (HCO3- )
– Biphosphate (HPO4-2 )

Biphosphate

15
 Conjugate acids and bases

• The acid and its corresponding base

or vice versa are called Conjugate
pair

• Eg: HCl and Cl- , H2CO3 and HCO3-

12/8/21
 Lewis acid Base Concept-1923
• Base: Any substance which donates a pair of
electrons
• Acid: Any substance which accepts a pair of
electrons

12/8/21
 Sources of Acids & Bases in body
ACIDS BASES
• Gastric Juice-HCl  Protein metabolism
• Cellular respiration- CO2 (deamination) -Ammonia
•  Blood, Pancreatic juice-
Metabolic end products -
Organic acids Bicarbonate
•  Dietary sources- Citrus
Blood- Carbonic acid
• Amino acid/Protein fruits - Bicarbonate,
metabolism- Sulphuric, Phosphates etc
Phosphoric acid

12/8/21
 Acids Bases
Fixed acids Volatile acids Ammonia
lactate, pyruvate, acetoacetate, uric acid carbon dioxide Bicarbonate

12/8/21
 pH ---Potential Hydrogen
Definition: Negative logarithm of
hydrogen ion concentration
• PH= - Log [H+]
• Expresses hydrogen ion concentration in solutions
• Water ionizes to a limited extent to form equal amounts of H+ ions and
OH- ions.
• It is Amphoteric
H 2O H+ + OH-

• H+ ion is an acid
• Hydroxonium ion is an acid
• OH- ion is a base

• PH of 7 is said to be neutral PH (100 nmol/L

Hydrogen ion) 20
 pH SCALE
• Pure water is Neutral
– ( H+ = OH- )
• pH = 7
H+
• Acid OH- H-
+
H OH- +
+
H
H+ + OH OH- H+
– ( H+ > OH- ) H H+
OH- OH-
H+
OH- H+
OH- H -
+
H +
• pH < 7 OH- H+ OH- OH
H+ OH-
3
• Base 1
H+ OH-
– ( H+ < OH- ) OH-
2
• pH > 7 ACIDS, BASES OR NEUTRAL???

• Normal blood pH is 7.35 - 7.45

• pH range compatible with life is
6.8 - 8.0 21
 pH SCALE
• pH = 4 is more acidic than pH
=6
• pH = 4 has 10 times more
free H+concentration than
pH = 5 and 100 times more
free H+ concentration than
pH = 6

DEATH ACIDOSIS NORMAL ALKALOSIS DEATH

6.8 7.3 7.4 7.5 8.0

Venous Arterial
22 Blood Blood
pH SCALE

23
 CHANGES IN CELL EXCITABILITY
• pH decrease (more acidic) depresses the
central nervous system
– Can lead to loss of consciousness
• pH increase (more basic) can cause over-
excitability
– Tingling sensations, nervousness,
muscle twitches

24
 INFLUENCES ON ENZYME ACTIVITY
• pH increase or decrease can alter the shape of
the enzyme rendering it non-functional
• Changes in enzyme structure can result in
accelerated or depressed metabolic actions
within the cell

25
 Dissociation Constant (KA)
• Definition: It is a constant ratio between
dissociated and un dissociated particles

• Ka= [H+] [A-] / [HA]

• PH at which half ionization occurs is Pka

12/8/21
 Henderson Hesselbach’s equation

• Used for calculation of PH of solution

For an acid,
• PH = Pka + Log [base]/[acid] or
• PH = Pka + Log [Salt]/[acid]
• PH =Pka when Concentration of acid =
concentration of base (half dissociated).
12/8/21
 Types
• Strong Acids and Bases: Those which
dissociate completely.
Eg: HCl and NaOH

• Weak acids and Bases: Those which

dissociate incompletely < 50%.
Eg: H2CO3 and HCO3-

12/8/21
 ACIDOSIS ALKALOSIS
A relative increase in A relative increase in
hydrogen ions results in bicarbonate results in
acidosis alkalosis

H+ OH - H +
OH -

29
Regulation of Acid Base Balance in Body

H +
HCO3 -

12/8/21
 ACID-BASE BALANCE
Derangements of
hydrogen and
bicarbonate
concentrations in
body fluids are
common in disease
processes

31
 Three systems regulating Acid
base balance

Buffer
system

Respiratory
Renal system
12/8/21 32
system
 Buffers
• Definition : These are solutions
or substances which resist change
in PH which is expected on addition
of acid or base.

• Weak acid and its salt with a strong base

• Weak base and its salt with a strong Acid

Eg: carbonic acid and Sodium Bicarbonate buffer,

Acetic acid and Sodium acetate, Phosphate buffer.
12/8/21
 Action of Buffer depends on

1. Concentration of acid and salt

2. Value of PK
3. Most effective when pH = pKa
Representation of Buffer on HH Equation,
pH= pKa + log [Salt] /[Acid]
Action of buffer will be maximum when
pH=pKa ± 1
12/8/21
 Mechanism of action of Buffer
• Depends on the pH of the
solution
• They convert –
Strong acid- weak acid
Strong Base- Salt
• Prevent change in pH of the
solution

12/8/21
 Action of buffer
acid base

Buffer Buffer
pH 7.0 pH 7.0

pH 6.8 pH7.2

Addition of Acid Addition of Base

to Buffer to Buffer
12/8/21
 Alkali Reserve
• Acids are produced in body in excess of alkali

• Neutralization requires more alkali

component of buffers .

• Hence alkali is reserved in body more than

acids

12/8/21
 Types of Buffers
58% - 52% tissues 42% - 40% -Bicarbonate,
6% RBCs 1% Phosphate,1% Protein

Intracellular RBCs Extracellular

K+ Protein / KHbO2 / NaHCO3 /

H+ Protein HHbO2 H2CO3

K2HPO4 / KH2PO4 KHCO3 / Na2HPO4 /

H2CO3 NaH2PO4

KHCO3 / HbO2/ Na+ Protein /

12/8/21 H2CO3 HHb H+ Protein
 Buffers of Body fluids
• First line of defence against acid base
disturbance
• Starts within seconds and brings the pH nearer
to normal
• Three buffers are most important
1. Bicarbonate buffer ( Most important)
2. Phosphate buffer ( Urinary buffer)
3. Protein buffer (Tissue, Hb, Plasma)

12/8/21
 Bicarbonate Buffer
• Most important buffer
• Main buffer in ECF (40%)—65% in plasma, but also
ICF ( RBCs)
• It converts strong non volatile to volatile acids
• Works in association with renal and respiratory
system
• Transporter of Carbon dioxide in plasma

12/8/21
 BICARBONATE BUFFER SYSTEM
Predominates in extracellular fluid (ECF)

HCO3- + added H+ H2CO3

H2CO3
HCO3-

41
 BICARBONATE BUFFER SYSTEM
This system is most important because the
concentration of both components can be
regulated:
– Carbonic acid by the respiratory system
– Bicarbonate by the renal system

42
 BICARBONATE BUFFER SYSTEM
CO2 + H2O H2CO3 H+ + HCO3-
Hydrogen ions generated by metabolism or by
ingestion react with bicarbonate base to form more
carbonic acid
H2CO3 HCO3-

43
 Representation of Bicarbonate buffer
• PH= Pka+ log [ HCO3-] / [H2CO3]
PH =7.4, [HCO3-]= 24mEq/L,
[H2CO3]=1.2mEq/L
• Hence on substituting ,
PKa= 6.1
• PH>Pka –Not an ideal buffer but
high concentration in plasma makes
it the best buffer
• Replenished continuously
• Base : Acid = 20:1 ( Alkali reserve)

12/8/21
45
 Phosphate buffer
• Important intracellular buffer
• Urinary buffer ( Acidification of
urine)
• Acts best at physiological pH(pKa
= 6.8)
• Wide range buffer. Most effective
• Ratio of 4:1( Alkali reserve)
• Low concentration (1mmol/L).not
a major buffer
• Regulated by the renal system
12/8/21
 PHOSPHATE BUFFER SYSTEM
Na2HPO4 + H+ NaH2PO4 +Na+
Most important in the intracellular system
Alternately switches Na+ with H+
Disodium hydrogen
phosphate

H + + Na2HPO4

Click to NaH2PO4 + Na+

animate
47
 PHOSPHATE BUFFER SYSTEM
Regulates pH within the cells and the urine

– Phosphate concentrations are higher

intracellularly and within the kidney tubules

– Too low of a
concentration in
ECF to have much HPO4 -2

importance as an
ECF buffer system
48
 PROTEIN BUFFER SYSTEM
– Behaves as a buffer in both plasma and cells
– Hemoglobin is by far the most important protein
buffer in RBCs
– Plasma Proteins (Albumin) in ECF
Ionisable groups
Most abundant -Acidic & Basic
in body(75%) Amphoteric nature

Act instantly
with
millisec Na Pr/HPr
KPr/HPr

Carbamino compound 49
Carrier of CO2
 Pr - added H+ + Pr -

12/8/21 Amino, Carboxyl, Guanidino & Imidazole groups

 PROTEIN BUFFER SYSTEM

H+ H+ H+ H+ H+ OH- H+ OH-
OH- H +

H+ OH-
OH- - - -+ - - - -- H+
- + ++
++ + -
- - + + + OH-
- -+ +
+ + - H+
H-+
OH -- +
-
- + - H+
- + +++
- + + - OH-
H+
- + + - H+
OH-
+
- - - - - - - -
OH- OH- H+
H + H
+

H+ HOH
+ -

H+ H +

51
 Hemoglobin buffer
Hemoglobin is better buffer than plasma proteins

1gm Plasma protein binds – 0.110meq H+

Histidine with
Imidazole ring 1gm Hb binds --0.183meq H+

12/8/21
As hemoglobin releases O2 it gains a great affinity for H+
 ISOHYDRIC TRANSPORT OF CARBON DIOXIDE

Hemoglobin buffers H+ from metabolically

12/8/21 produced CO2 in the plasma only
H+ generated at the tissue level from the dissociation
of H2CO3 produced by the
addition of CO2
Bound H+ to Hb (Hemoglobin) does not
contribute to the acidity of blood

As H+Hb picks up O2 from the lungs the Hb which

has a higher affinity for O2 releases H+ and picks
up O2 Liberated H+ from H2O combines with HCO3-
O2 O2

Hb 54
O O
• Venous blood is only slightly more acidic than
arterial blood because of the tremendous
buffering capacity of Hb
• Even in spite of the large volume of H+
generating CO2 carried in venous blood

55
 Cellular buffers
• Cellular pH = 6.8-7.2 H+

• PH is important for optimum K+

cell
functioning
• Intracellular buffers are
protein,Phospahte and Bicarbonate
buffers
• Ions like Na+,K+,Ca2+ plays an H+

important role K+
cell
• trancellular shift is seen
• Mainly in skeletal tissue & bone
12/8/21
 ELECTROLYTE SHIFTS

• When reabsorbing Na+

from the filtrate of the
renal tubules K+ or H+
is secreted
(exchanged)
• Normally K+ is
secreted in much
greater amounts
than H+
K+ Na+
H+

K+
57 57
 INFLUENCES ON K LEVELS +

• If H+ concentrations are high (acidosis) ,then

more H+ is secreted
• This leaves less K+ than usual excreted
• The resultant K+ retention can affect cardiac
function and other systems

K+ Na+
H+

58
 1) Buffer Systems
2) Respiratory Responses
3) Renal Responses
4) Intracellular Shifts of Ions

59
 Respiratory Regulation
• Second line of defence
• Acts in minutes
• Acts by,
1. Exchange of gases(regulates pCO2)
2. Regulates Carbonic acid levels (with
Bicarbonate buffer)
3. Chemo receptors are pH sensitive
regulating respiratory rate

12/8/21
 ISOHYDRIC TRANSPORT OF CARBON DIOXIDE

12/8/21
 RESPIRATORY CENTER
Stimulation and limitation of
respiratory rates are controlled by
the respiratory center

Neurons in the medulla

oblongata and pons
constitute the
Respiratory Center

Pons
Respiratory centers
Medulla oblongata
Control is accomplished by
responding to CO2 and H+
62
concentrations in the blood
 CHEMOSENSITIVE AREAS
• Chemo sensitive areas of the respiratory center
are able to detect blood concentration levels of
CO2 and H+
• Increases in CO2 and H+ stimulate the respiratory
center
– The effect is to raise
respiration rates
– But the effect
diminishes in
1 - 2 minutes
CO
CO
CO
2
22
Click to increase CO2 CO
CO
CO2
2 2CO 63
CO
CO22
 CHEMORECEPTORS
• Chemo receptors are also present in the carotid
and aortic arteries which respond to changes in
partial pressures of O2 and CO2 or pH
• Increased levels of
CO2 (low pH) or
decreased levels of
O2 stimulate
respiration rates
to increase

64
 CHEMORECEPTORS
Overall compensatory response is:
– Hyperventilation in response to increased
CO2 or H+ (low pH)
– Hypoventilation in response to decreased
CO2 or H+ (high pH)

65
 RESPIRATORY CONTROL OF pH
cell production of CO2 increases

CO2 + H2O H2CO3

H2CO3 H+ + HCO3-
H+ acidosis; pH drops

H+ stimulates respiratory center in medulla oblongata

rate and depth of breathing increase

CO2 eliminated in lungs

pH rises toward normal 66

 1) Buffer Systems
2) Respiratory Responses
3) Renal Responses
4) Intracellular Shifts of Ions

67
 RENAL RESPONSE
• The kidney compensates for Acid - Base imbalance
within 24 hours and is responsible for long term control
• The kidney responds in 4 ways:
1. Excretion of H+ Ion
2. Reabsorption of HCO3-
3. Excretion of Titratable acid
4. Excretion of NH4+ ions
– In Acidosis
• Retains bicarbonate ions and eliminates hydrogen
ions
– In Alkalosis
• Eliminates bicarbonate ions and retains hydrogen
ions 68
ACIDIFICATION OF URINE BY EXCRETION OF HYDROGEN
Capillary Distal Tubule Cells Notice the
H+ - Na+ exchange t
maintain electrica
neutrality

Dissociation of
carbonic acid
Na+ +
H23CO
HCO -
+3 H+
NaHCO3
NaHCO3

H2O+CO2
Click MouseHto See
Animation Again Tubular 69
12/8/21
 ACIDIFICATION OF URINE BY EXCRETION OF AMMONIA
Distal Tubule Cells
Capillary
Glutamine- NH2
Glutamine

NH
NH3 3 H++
WHAT
HAPPENS
NEXT?
Tubular urine to
be excreted

71
ACIDIFICATION OF URINE BY EXCRETION OF AMMONIA
Distal Tubule Cells
Notice the
Capillary
H+ - Na+
NH3 exchange to
maintain
electrical
Dissociation of neutrality
carbonic acid
NaNaCl
+
+ Cl-
HCO -
H32CO+3 H+
NaHCO3
NaHCO3
NH3Cl-
NH4Cl

Click
Click Mouse
Mouse to See
to Start Tubular Urine 72
 RESPIRATORY & EXCRETORY
RESPONSE
CO2 + H2O H2CO3 H+ + HCO3-

Hyperventilation removes
H+ ion concentrations Kidneys eliminate or retain
H+ or bicarbonate ions
Hypoventilation increases
73
H+ ion concentrations
 1) Buffer Systems
2) Respiratory Responses
3) Renal Responses
4) Intracellular Shifts of Ions

74
 HYPERKALEMIA
• Hyperkalemia is generally associated with
acidosis
– Accompanied by a shift of H+ ions into cells
and K+ ions out of the cell to maintain
electrical neutrality

H +
K +
75
 HYPOKALEMIA
• Hypokalemia is generally associated with
reciprocal exchanges of H+ and K+ in the
opposite direction
– Associated with alkalosis
• Hypokalemia is a depressed serum K+

H +
K +
76
 Disorders Of Acid Base
Balance

D
Abnormalities in the acid base balance of the body associated
12/8/21
with change in Plasma pH
 Abnormal functioning of
Respiratory or Renal
system
 Accumulation or loss of
acids or bases in the body

 Exogenous administration
or endogenous production
 Compensatory
mechanisms bring the pH
to near normal

H +
HCO 3
-
78
 ACIDOSIS ALKALOSIS
A relative increase in A relative increase in
hydrogen ions results in bicarbonate results in
acidosis alkalosis pH > 7.45
pH < 7.35

H + OH - H +
OH -

79
 Classification
• Simple ABD
Based on the Source and direction in which pH is altered

– Respiratory Acidosis
Respiratory system
– Respiratory Alkalosis affected
– Metabolic Acidosis
Renal system
– Metabolic Alkalosis affected

• Mixed ABD –Combinations of simple ABD

12/8/21
 ACIDOSIS
Causes
1. Increase in Acid:
– Increase in H2CO3 (CO2)
– Increase in Non carbonic acids
2. Decrease in Base
– A decrease in HCO3-
Both lead to a decrease in the ratio of 20:1

H2CO3 HCO3 -
81
 ACIDOSIS
decreased failure of metabolic production absorption of prolonged
removal of kidneys to acid of keto acids metabolic acids diarrhea
CO2 from excrete from GI tract
lungs acids

accumulation accumulation excessive loss

of CO2 in blood of acid in blood of NaHCO3
from blood

Deep
vomiting
from
Respiratory Metabolic GI tract
Increase in
acidosis plasma H+ acidosis
concentration Kidney
disease
(uremia)
Depression of
nervous system 82
 ALKALOSIS
Causes
1. Decrease in Acid:
– Decrease in H2CO3 (CO2)
– Decrease in Non carbonic acids
2. Increase in Base
– Increase in HCO3-
Both lead to a Increase in the ratio of 20:1

H2CO3 HCO3 -
83
 ALKALOSIS
anxiety overdose high prolonged ingestion of excess
of certain altitudes vomiting excessive aldosterone
drugs alkaline drugs

hyperventilation loss of acid accumulation

loss of CO2 and of base
H2CO2 from
blood

respiratory metabolic
alkalosis alkalosis
decrease
in plasma H+
concentration

overexcitability
of nervous
system 84
 Compensation
 Occurs in same direction as the primary
variable by changing the counter variable
 Buffers are the first line of defence
 Respiratory system takes action in minutes
 Renal system brings back the pH to normal

12/8/21
12/8/21
 ACIDOSIS
H+
1) Respiratory Acidosis
2) Metabolic Acidosis H+
H+ H+
H + H+
H + H H +
+ + H +

H H +

H + H + H +
H +

H + H H
+ + H +

H + H +

H + H +
H+ H + H +

H+ H+ H+ H+ 87
 ALKALOSIS
• 1) Respiratory alkalosis H+
• 2) Metabolic alkalosis H+
H+ H+
H+
H+ H+
H+ H+ H+
H+ H+
H + H+
H+ H+ 88
 Anion Gap
• The major cation is
Na+
– Minor cations are
K+, Ca2+ , Mg2+
• The major anions are
HC03- and Cl-
(Routinely measured.)

– Minor anions include

albumin, phosphate,
sulfate (called
unmeasured anions).
– Organic acid anions
include lactate and
acetoacetate.
 Anion Gap
Law of electro neutrality:
Sum of the Anions in body = Sum of Cations in the body
– ve = +ve charges.

• Electro neutrality is maintained in ECF

• UA+ MA= UC +MC
• Unmeasured Anions = 14% of Anions
UA= Anion Gap(AG)
=[Na+] – ([HC03-] + [Cl-])
= 140 - (24 + 105) = 11
Normal =8-16 meq/L

Uses:
To classify Metabolic Acidosis
Treatment of these disorders
Anion Gap
 METABOLIC ACIDOSIS
Definition: Increase in plasma pH associated
with primary increase in acid or deficiency
of Bicarbonate

Causes :Increase in Acid

• Non Carbonic acid
Decrease in Base
• Loss of Bicarbonate ( GI/ Renal)

[HCO-3] / [H2CO3] = <20:1

92
 Classification-
Based on Anion gap

• High AG Metabolic Acidosis

• Normal AG Metabolic Acidosis
• Hyperchloremic acidosis

12/8/21
 METABOLIC ACIDOSIS
• Occurs when there is a decrease in the normal
20:1 ratio
Decrease in blood pH and bicarbonate level
• Excessive H+ or decreased HCO3-

-
H2CO3 HCO 3 3-
HCO
H 2CO 3

== 7.4
7.4
1 : 10
20 94
 High AG Metabolic
Acidosis
• Increase in Unmeasured Anions
Endogenous production – Lactate,
Pyruvate, Acetoacetate, β OH Butyrate
• Ingestion of Acids- Exogenous
Drugs, Poisoning
• Accumulation of endogenous acids
:Renal dysfunction
Enzymes
C6H12O6 2C3H6O3 + ATP (energy)
12/8/21
Lactic Acid
 Causes
• Lactic Acidosis
• Keto Acidosis- DM, Alcohol,
Starvation
• Strenuous Exercise
• Toxins – Ethylene glycol,
Methanol, ethanol,
Salicylates, Propyl glycol,
Pyroglutamic acid
• Renal Failure- Acute and
Chronic
12/8/21
 Normal / Low Anion gap
Metabolic acidosis
Loss of both Anions and cations
• GI loss – lower GI secretions -
Diarrhoea, GI fistula
• Renal tubular Acidosis – with
Hypo or Hyperkalemia
• Drugs - Diuretics
• Others – Acid loads, loss of
bicarbonate due to ketonuria,
Expansion acidosis,
Cation exchange resins.
12/8/21
 Hyperchloremic Metabolic
Acidosis

• Occurs in association with

normal AG
• Causes:
RTA, CA inhibitors, Ureteric
transplantation into gut

12/8/21
Clinical Features :

RS CVS
Hyper Depressed CNS
ventilation contractility Headache
Kussmal’s Arrhythmias Lethargy
respiration decreased Stupor
Pulmonary vascular Coma
edema compliance
 METABOLIC ACIDOSIS
H2CO3 : Carbonic Acid
HCO3- : Bicarbonate Ion
H2CO3 HCO3-
(Na+) HCO3-
(K+) HCO3-

1 : 20 (Mg++) HCO3-
(Ca++) HCO3-

Metabolic balance before onset of acidosis

pH 7.4 100
 METABOLIC ACIDOSIS

-
HCO 3

H 2CO 3

= 7.4
1 : 10

HCO3- decreases because of excess presence of ketones,

chloride or organic ion
101
pH 7.1
 BODY’S
METABOLIC ACIDOSIS
COMPENSATION
CO2 HCO3- + H+

- HCO3-
HCO 3
+
H 2CO 3 H+
CO2 + H2O

0.75 : 10
Acidic urine

- Hyperactive breathing to “ blow off ” CO2

- Kidneys conserve HCO3- and eliminate H+ ions in
acidic urine 102
 Diagnosis
 Clinical History & Examination
 ABG – pH< 7.35, PaCO2 , HCO3-
 Anion Gap
 Increased levels of Lactate , Pyruvate in
blood
 Electrolyte imbalance
 Blood Glucose levels
 Renal function tests- Uremia
 Plasma Osmolality
12/8/21
 Treatment

H2CO3 HCO3- Lactate

Lactate
containing
solution
0.5 : 10

-Therapy required to restore metabolic balance

- Potassium Supplementation, Correcting the
electrolyte imbalance 104
 Treatment
• Treating the underlying cause of metabolic acidosis
is the usual course of action
• control diabetes with insulin
• Treat poisoning by removing the toxic
substance from the blood
• Alkalinisation of urine
• Occasionally
dialysis is needed
to treat severe
overdoses and
poisonings 105
• Metabolic acidosis may also be
treated directly
– If the acidosis is mild, IV fluids
and treatment for the underlying
disorder may be all that's needed
– Glucose infusion with NS
– When acidosis is severe,
Bicarbonate may be given
intravenously
=0.3х Body weight х Base excess
– Shohl’s Solution also used

106
 METABOLIC ALKALOSIS
• A reduction in H+ in the case of metabolic
alkalosis can be caused by a deficiency of non-
carbonic acids
• This is associated with an increase in HCO3-

Net gain in HCO3- Loss of Non

carbonic Acids

107
METABOLIC ALKALOSIS

H2 CO HCO -
3 3

1 : 40
HCO3- increases because of loss of chloride ions or
excess ingestion of NaHCO3
pH = >7.45 108
 METABOLIC ALKALOSIS
Causes:
1) Ingestion of Alkaline Substances
2) ECF with sec hyperaldosteronism
hyperreninism
Vomiting ( loss of HCl ), Aspiration
Diuretics
Hypercalcemia ( PTH)
Def of Mg+, K+
3) ECF ,HTN, K+ def, Mineralocorticoid
excess
Renin Renin
Liddle’s ,Gittlemann’s syndrome

109
 Classification
• Chloride responsive
---- Loss of upper GI secretions
Responds to treatment with
Chloride solution
• Chloride resistant
-----Other causes which does not respond
to chloride treatment

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 METABOLIC ALKALOSIS
• Reaction of the body to alkalosis is to lower pH
by:
– Retain CO2 by decreasing breathing rate
– Kidneys increase the retention of H+

H+
H+
CO2 H+
CO2 H+

111
 METABOLIC ALKALOSIS
HCO3- + H+

H+
H2CO3 HCO3 - +
CO2 + H2O HCO3-

1.25 : 30
BODY’S COMPENSATION Alkaline urine
Breathing suppressed to hold CO2
kidneys conserve H+ ions and eliminate HCO3- in alkaline
urine 112
 Treatment
• Replacing water and electrolytes
(sodium and potassium)
• Chloride containing solution
• Treat the underlying cause
• Diuretics -Acetazolamide
• If very severe, dilute acid in the
form of Ammonium chloride or
0.1N HCL is given by IV
• Hemodialysis

113
 Paradoxical Acidura
• Seen in Metabolic Alkalosis
• K+ deficient states,
• ACTH/Cortisone therapy /GI loss/Cushing’s
syndrome

Acidic urine is excreted instead of alkaline

------ Transcellular shift and attempt to conserve K+

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 References
• Harrison’s Principles of Internal Medicine 17th
Edition
• Clinical Physiology Of Acid Base &Electrolyte
Disorders- B D Rose
• T/B of Biochemistry –Pankaja Nayak
• T/B of Biochemistry –Vasudevan
• Google

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 Disorders of Acid Base Balance Contd……..

Respiratory Acidosis and Alkalosis

Mixed Disorders

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 Respiratory Acidosis
The primary disturbance is an
[H2CO3] – Retention of CO2
Causes:
• Central: Drugs
Stroke, Infection, head injury
• Airway : Obstruction , Asthma
• Parenchyma: Emphysema,
Pneumoconiosis, Bronchitis,
ARDS,
• Neuromuscular : PM,
Kyphoscoliosis, MG, MD
• Miscellaneous : Obesity,
Hypoventilation
 RESPIRATORY ACIDOSIS
• Caused by hypercapnia due to
Increased retention
Decreased elimination
H2CO3 pH
•
CO2
pH
CO2 CO2
CO2 CO2
CO CO2 CO2
2

CO2CO2 CO2 CO2

pH CO2
CO2
118
 Types
• Acute : Bronchopneumonia, Status
Asthmaticus, Sedatives.
pH decreases drastically
• Chronic: COPD
pH fall is minimal due compensatory
mechanisms

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 RESPIRATORY ACIDOSIS

CO2 CO2
-
HCO 3 CO2
CO2

H 2CO 3

2 : 20

breathing is suppressed holding CO2 in body

pH = 7.1
120
 Compensation
• Buffers : Carbon dioxide --H2CO3
• Kidneys eliminate more H+
Retain more Bicarbonate ion
Increased elimination of Ammonium ion is
seen
Activation of enzymes like CA,Gutaminase

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 RESPIRATORY ACIDOSIS
H2CO3

-
HCO3-
CO
H 3 HCO3-
H 2CO 3
+
H+

2 : 30
acidic urine
BODY’S COMPENSATION
-kidneys conserve HCO3- ions to restore the
normal 40:2 ratio (20:1)
-kidneys eliminate H+ ion in acidic urine 122
 Clinical features
• Depends on the severity of condition
• Increased PaCO2- Anxiety,dyspnoea,
psychosis, hallucinations , Coma
• Myotonic jerks, day time somnolence,
personality changes, tremors
• Increased ICP- Papilledema, Abnormal
reflexes, muscle weakness

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 Diagnosis
Arterial blood gases
History & Clinical examination (RS)
Pulmonary function tests – lung volumes,
Spirometry, Diffusion capacity of
CO2,SPO2
Non pulmonary causes: hematocrit,
neuromuscular function,
 Treatment of respiratory acidosis
• If severe & life threatening: Treat underlying
cause & restore alveolar ventilation
simultaneosly
• Oxygen administration cautiously
• Sudden correction is hazardous
• Chronic – Improve the respiratory function
 Respiratory Alkalosis
primary disturbance is decrease
of [H2CO3] in plasma

• CO2 H2CO3 pH

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 respiratory alkalosis
the Causes:
• Hysterical – Hyperventilation
syndrome
• Hypoxia- High altitude
• Injury to brain stem
• Raised ICP
• Drugs: Salicylate poisoning
• Iatrogenic: ventilator misoperation
 RESPIRATORY ALKALOSIS
• Normal 20:1 ratio is increased
– pH of blood is above 7.4

H2H2 C3O
CO 3
HCO3-
HCO -

== 7.4
3

0.51 : 20

128
 RESPIRATORY ALKALOSIS
• Kidneys compensate by:
– Retaining hydrogen ions
– Increasing bicarbonate excretion
HCO3-
HCO3-
H+
H+
HCO3- HCO3-
H+
H+ H+
HCO3-
HCO3- H+
HCO3-
H+
HCO3- H+
HCO 3
-
H+
HCO3- H
+

H+ 129
 Clinical features
• Depends on the severity and duration
• Due to hypoperfusion
• Dizziness, Mental confusion, Seizures, Cardiac
arrythmias
• Hyperventilation, Parasthesia, numbness,
fatigue, chest wall tightness, dizziness, tetany

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 Diagnosis
History & Clinical examination (RS)
Arterial blood gases
Serum Electrolytes

Pulmonary function tests – lung volumes,

Spirometry, Diffusion capacity of
CO2,SPO2
Treatment of respiratory alkalosis
• Treat underlying cause
• restore alveolar ventilation: Ventilator support
• Reassurance
• Rebreathing in paper bag during symptoms
• Attend to psychiatric problem
• Beta Blockers
 Mixed Disorders

• Independently coexistent disorders and not

merely compensation
• pH may be Normal or altered
• Discrepancy in ∆ AG or ∆ HCO3-
• Two or more types may coexist

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 Mixed Metabolic and respiratory

Met. Acidosis Met.Acidosis Met Alkalosis Met Alkalosis

with with Resp. with Resp with Resp
Resp.Alkalosis Acidosis Acidosis Alkalosis

●
LA ●
Severe ●
Liver
●
Sepsis Pneumonia ●
COPD on disease
●
Salicylate ●
Pul Edema Diuretics and
poisoning ●
Drug Abuse diuretics

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 Mixed Metabolic Disorders

Met. Acidosis with Met.Acidosis with

Met Alkalosis Met Acidosis

●
Diarrhoea with Lactic
Acidosis
●
Uraemia with Vomiting ●
Toluene toxicity
●
Treatment of DKA

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triple acid-base disturbance

respiratory acidosis respiratory alkalosismetabolic

metabolic acidosis acidosis
and alkalosis and metabolic alkalosis

fever; vomiting; diarrhea

Cardiopulmo
●
●
(food poisoning Gastro
●
enteritis)

nary disease; ●
Alcoholic Keto
vomiting Acidosis
 Acid Base Parameters
•

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 SEVEN STEPS TO ACID BASE ANALYSIS
(for highly effective clinicians!)

1.COMPREHENSIVE HISTORY AND PHYSICAL EXAMINATION

2.ORDER SIMULTANEOUS ABG AND CHEMISTRY PROFILE
3.ASSESS ACCURACY OF DATA
4.IDENTIFY THE PRIMARY DISTURBANCES
5.CALCULATE THE EXPECTED COMPENSATION
6.CALCULATE THE "GAPS"
7.USE ACID BASE MAPS

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 END
ACID - BASE BALANCE

139
12/8/21 Thank You